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REQUEST FOR PROPOSAL: SMCPS-2021-01-DSS-DC A/E CONSULTING FOR MODERNIZATION FEASIBILITY STUDY FOR ELEMENTARY SCHOOLS Commissioned by: St. Mary’s County Public Schools 27190 Point Lookout Road Loveville, Maryland 20656 Phone: (301) 475-4256 Fax: (301) 475-4255 Mrs. Karin M. Bailey, Chairman Mrs. Cathy Allen, Vice Chairman Mrs. Mary Washington, Member Mr. James J. Davis, Member Mrs. Rita Weaver, Member Ms. Naggena Ohri, Student Member Dr. J. Scott Smith, Secretary/Treasurer and Superintendent of Schools Mr. Jeff Walker, Ph. D., Assistant Superintendent of Supporting Services Ms. Paola Laino, Director of Design and Construction Mr. Wes King, Project Management Coordinator PREPARED BY: St. Mary's County Public Schools 27190 Point Lookout Road Loveville, Maryland 20656 July 29, 2020

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Page 1: REQUEST FOR PROPOSAL: SMCPS-2021-01-DSS-DC A/E …

REQUEST FOR PROPOSAL:

SMCPS-2021-01-DSS-DC

A/E CONSULTING FOR

MODERNIZATION FEASIBILITY STUDY

FOR ELEMENTARY SCHOOLS

Commissioned by:

St. Mary’s County Public Schools

27190 Point Lookout Road

Loveville, Maryland 20656

Phone: (301) 475-4256

Fax: (301) 475-4255

Mrs. Karin M. Bailey, Chairman

Mrs. Cathy Allen, Vice Chairman

Mrs. Mary Washington, Member

Mr. James J. Davis, Member

Mrs. Rita Weaver, Member

Ms. Naggena Ohri, Student Member

Dr. J. Scott Smith, Secretary/Treasurer and

Superintendent of Schools

Mr. Jeff Walker, Ph. D., Assistant Superintendent of Supporting Services

Ms. Paola Laino, Director of Design and Construction

Mr. Wes King, Project Management Coordinator

PREPARED BY:

St. Mary's County Public Schools 27190 Point Lookout Road

Loveville, Maryland 20656

July 29, 2020

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A/E Consulting for Modernization Feasibility Study 2

REQUEST FOR PROPOSAL

CERTIFIED MINORITY BUSINESS ENTERPRISES ARE ENCOURAGED TO RESPOND TO THIS

SOLICITATION NOTICE

Your firm has expressed an interest in submitting a Proposal for the Project identified below. Proposal

documents are attached.

1. A/E Consulting for Modernization Feasibility Study for Elementary Schools,

RFP# SMCPS-2021-01-DSS-DC, Dated: July 29, 2020.

2. PROJECT DESCRIPTION: St. Mary’s County Public Schools (SMCPS) is requesting Technical Proposals

from firms to provide a Feasibility Study for the Modernization of two (2) Elementary Schools. The firm(s)

to which the contract is awarded will be required to provide a complete survey of key components for

Mechanicsville Elementary School and Lettie Marshall Dent Elementary School. This study shall

recommend corrections for all deficiencies noted as well as provide cost estimates for corrections. The

Board of Education of St. Mary’s County has the right to make multiple awards under this RFP.

3. PRE-PROPOSAL CONFERENCE: NONE.

4. CLOSING DATE FOR RECEIPT OF PROPOSALS: Three (3) copies of the Technical Proposals must arrive

at the Issuing Office no later than 2:00p.m. on August 12, 2020 and must be delivered to Issuing Office

and Contracting Officer:

St. Mary’s County Public Schools

Department of Design and Construction

Attn: Wes King,

Project Management Coordinator

27190 Point Lookout Road

Loveville, MD 20656

No Faxed Proposals will be accepted. Offerors mailing proposals should allow sufficient mail delivery

time to insure timely receipt by the Issuing Office. Proposals or unsolicited amendments to proposals

arriving after the closing time and date will not be considered. Because of the rural location of the

SMCPS, Federal Express will not guarantee delivery to the SMCPS by any specific time.

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TABLE OF CONTENTS

SECTION I:

GENERAL INFORMATION FOR OFFERORS 4

SECTION II:

SCOPE OF SERVICES 8

SECTION III:

PROPOSED PROJECTS 8

SECTION IV:

EVALUATION & SELECTION PROCEDURES

A. General 8

B. Technical Proposal Requirements 8

C. Technical Proposal Evaluation 10

SECTION V:

APPENDICES

Appendix A. Sample Agreement between Owner and Architect/Engineer 12

Appendix B. Contract Affidavit 18

Appendix C. Sex Offender Certification 19

Appendix D. Architect / Engineer Qualifications – Standard Form 330 20

Appendix E. Contractor’s Qualification Questionnaire 21

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SECTION I: GENERAL INFORMATION FOR OFFERORS:

1. PREPARATION OF PROPOSAL: The Proposals must be labeled with the following notations:

TECHNICAL PROPOSAL: “RFP: SMCPS-2021-01-DSS-DC Modernization Feasibility Study for Elementary

Schools, St. Mary’s County Public Schools” bearing Offeror’s name and address.

PROPOSAL DUE DATE: 2:00 p.m., August 12, 2020

2. ISSUING OFFICE AND CONTRACTING OFFICER:

St. Mary’s County Public Schools

Department of Design and Construction

Attn: Wes King,

Project Management Coordinator

27190 Point Lookout Road

Loveville, MD 20656

3. CLOSING DATE FOR RECEIPT OF PROPOSALS: Three (3) copies of the Technical Proposal must arrive

at the Issuing Office no later than: 2:00 p.m., August 12, 2020 and must be delivered to:

St. Mary’s County Public Schools

Department of Design and Construction

Attn: Wes King,

Project Management Coordinator

27190 Point Lookout Road

Loveville, MD 20656

Faxed proposals will not be accepted. Offerors mailing proposals should allow sufficient mail delivery

time to insure timely receipt by the Issuing Office. Proposals or unsolicited amendments to proposals

arriving after the closing time and date will not be considered.

4. DURATION OF PROPOSAL OFFER: Proposals, including price proposals when requested, are

irrevocable for 120 days following the closing date of this RFP. This period may be extended by written

mutual agreement between the Offeror and SMCPS. Once a proposal is accepted all prices, terms

and conditions shall remain unchanged throughout the contract period.

5. QUESTIONS AND INQUIRIES: Questions and inquiries shall be addressed to the Contracting Officer

listed in paragraph 2 and must be submitted in writing (they may be emailed to Wes King

[email protected]) no later than 2:00 p.m. on August 5, 2020.

6. ADDENDA TO THE RFP: If it becomes necessary to revise any part of this RFP, addenda will be provided

to all Offerors who receive the initial RFP. Acknowledgment of the receipt of all amendments,

addenda, and changes issued shall be required from all Offerors receiving the RFP. Oral explanations

or instructions shall not be binding; only written addenda are binding.

7. CANCELLATION OF THE RFP: SMCPS may cancel this RFP, in whole or in part, at any time before the

opening of the proposals.

8. MODIFICATIONS OR WITHDRAWAL OF PROPOSALS: Offerors may modify or withdraw their proposals

by sending a written notice which must be received at the Issuing Office before the time and date set

for receipt of proposals. Emailed modifications or withdrawals received before this date will also be

accepted.

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9. PROPOSAL ACCEPTANCE: This Request for Proposal (RFP) creates no obligation on the part of the

SMCPS to award a contract or to compensate Offerors for proposal preparation expenses. SMCPS

reserves the right to accept or reject any and all proposals, in whole or in part, received as a result of

this RFP.

10. ECONOMY OF PREPARATION: Proposals should be prepared simply and economically, providing a

straight-forward, concise description of the Offeror's offer to meet the requirements of the RFP. It should

respond to each requested item of information in the order that the items appear.

11. ORAL PRESENTATION: Offerors whose proposals are reasonably susceptible of being selected for

award may be required to make individual presentations to the Evaluation Committee. SMCPS will

advise Offerors as to the date, time and place.

12. INCURRED EXPENSES: SMCPS will not be responsible for any costs incurred by any Offeror in preparing

and submitting a proposal.

13. TRANSFERS AND SUBCONTRACTING: The Offeror to whom this contract is awarded may not transfer

or subcontract, in whole or in part, any portion of this contract without the written permission of SMCPS.

14. COMPLIANCE WITH LAWS: By submitting a response to this solicitation, the Offeror, if selected for

award, agrees that it will comply with all federal, State and local laws, rules, regulations, and

ordinances applicable to its activities and obligations under the contract.

15. PUBLIC INFORMATION ACT NOTICE: Offerors should give specific attention to the identification of

those portions of their proposals which they deem to be confidential, proprietary information or trade

secrets and provide any justification of why such materials should not be disclosed by SMCPS under

the Access to Public Records Act, State Government Article, Title 10, Subtitle 6, Annotated Code of

Maryland.

16. AWARD: After considering both the technical and financial factors set forth in this RFP, the

Committee will make a recommendation that the contract be awarded to the responsible Offeror

whose proposal is determined to be the most advantageous to the SMCPS. Should the successful

Offeror to whom the contract is awarded fail or be unable to execute the contract, for any reason,

within ten (10) calendar days after notification of award, then that Offeror shall be liable to SMCPS for

actual damages incurred by SMCPS. SMCPS reserves the right to cancel the award of any contract

prior to execution by all parties without any liability on the part of SMCPS.

17. PROTESTS: Interested parties may protest a prequalification decision of SMCPS by submitting a

protest in writing to the Superintendent of Schools, St. Mary’s County Public Schools, 23160 Moakley

Street, Leonardtown, Maryland 20650 within ten (10) calendar days of the decision. A complete copy

of the protest and all supporting documentation must also be submitted within ten (10) calendar days

of the decision to the Division of Supporting Services, Department of Design and Construction, St. Mary’s

County Public Schools, 27190 Point Lookout Road, Loveville, Maryland 20656. SMCPS and the Board

may deny untimely protests.

The protest shall identify the prequalification decision being protested, and the Project for

which the prequalification decision was made. The written protest shall specify the

grounds for the protest and shall include a detailed statement of the factual and legal

basis for the protest, including:

a. The name, address and telephone number of the protestor

b. The relevant facts relied upon for the protest

c. Any language from the prequalification package relied upon for the protest

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d. Any information contained in the Contractor’s prequalification application relied

upon for the protest

e. Citation of any rules, regulations, case law, statutes or other legal authority relied

upon for the protest

f. Any other information relied upon for the protest

The written protest shall also include copies of all documents, data, records or other

evidence relevant to the protest. The burden of producing the foregoing information,

documents, data, records and other relevant evidence is on the protestor. The burden of

persuasion on the merits of the protest is also on the protestor.

A decision on the protest, and appeals thereof, shall be made in accordance with the requirements

of Section 4-205(c) of the Education Article of the Annotated Code of Maryland. Upon receipt of a

timely and complete written protest, an initial determination on the protest shall be made by the

Superintendent of SMCPS or his/her designee. The decision of the Superintendent may be appealed

to the Board, if taken within thirty (30) days after the date of the Superintendent’s decision. The decision

of the Board may be further appealed to the State Board of Education if taken in writing within thirty

(30) days after the decision of the Board.

18. CONTRACTOR'S REQUIRED INSURANCE:

18.1 Insurance coverage shall be provided as required by the General Conditions.

18.2 Property insurance covering any equipment owned by the contractor which is used or stored on

SMCPS property.

18.3 Certificates of the contractor's insurance containing evidence of the Hold Harmless Clause

protecting the Board of Education of St. Mary’s County shall be filed with SMCPS and shall be subject

to their approval for adequacy of protection. No contract will be awarded until appropriate

certificates of insurance are filed with and approved by the Contracting Officer.

18.4 The above insurance shall remain in full force and effect for the term of the contract.

19. SUBCONTRACTOR’S INSURANCE: If any of the work under this contract is subcontracted, the

Contractor shall require the subcontractors, or anyone directly or indirectly employed by any of them

to procure and maintain the same insurance coverage in the same amounts specified above.

20. ORDER OF PRECEDENCE: To the extent that any provisions of the Proposal prepared by the

Contractor are inconsistent with the provisions of the Request For Proposal prepared by the SMCPS, the

Contractor shall ask SMCPS for a written ruling and will comply with the ruling.

21. CONTRACT AFFIDAVIT: All respondents must truthfully complete the Contract Affidavit found in

Appendix B of this RFP package and submit it with their technical proposal.

22. CONTRACT DOCUMENTS: Contractors should become familiar with the contract documents listed

below, all of which are incorporated by reference into the final contract.

A) Request For Proposal prepared by St. Mary’s County Public Schools including all

addenda;

B) Technical Proposal prepared and submitted by the Architect/Engineer;

C) Appendix A. Agreement Between Owner and Architect/Engineer;

D) Appendix B. Contract Affidavit

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23. LICENSES, REGISTRATION AND QUALIFICATIONS: All work performed by the Architect/Engineer shall

conform to all State and local codes and ordinances and such other statutory provisions that pertain

to this class of work. Such codes, rules, regulations and local ordinances are to be considered part of

these specifications. SMCPS reserves the right to require that the contractor demonstrate that it has

the skills, equipment and other resources to satisfactorily perform the nature and magnitude of work

necessary to complete the project. SMCPS has the option of requiring all personnel working on this

contract to have copies of their license/registration forms on file with the Contracting Officer at SMCPS.

24. PROJECT AUTHORIZATION: Individual projects will be authorized through the issuance of a purchase

order which shall incorporate all of the terms and conditions set forth in the Agreement Between Owner

and Architect/Engineer. The Architect/Engineer shall provide an itemized proposal for a scope of work

prepared by SMCPS. All work authorized by purchase order shall be governed by the terms and

conditions of the Agreement.

25. RESERVATION OF SMCPS RIGHTS: Board of Education of St. Mary’s County reserves the right to

accept or reject any and all proposals, in whole or in part, received as a result of this RFP, to not make

an award, to waive minor irregularities, or to negotiate with all responsible Offerors in any manner

necessary, in order to serve the best interests of St. Mary’s County Public Schools.

(End of Section)

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SECTION II: SCOPE OF SERVICES

St. Mary’s County Public Schools (SMCPS) is requesting proposals from qualified and experienced firms

to provide a feasibility study for the modernization of Mechanicsville Elementary School (MES) and

Lettie Marshall Dent Elementary School (LMDES). The firm to which the contract is awarded will be

required to provide a condition assessment report that identifies and documents current facility

conditions and deficiencies.

Mechanicsville Elementary School is located at 28585 Three Notch Road, Mechanicsville, MD 20659.

This building was constructed in 1951 and had additions in 1960 and 1979. A complete survey of key

components for this school including, but not limited to asbestos abatement, electrical upgrades,

ceiling, flooring, fire alarm, public address system and windows will be required. This study shall

recommend corrections for all deficiencies noted as well as provide cost estimates for corrections for

each deficiency. The study shall also include considerations for exterior improvements to the school.

A recently completed window condition assessment was completed and will be shared with the

selected firm for reference.

Lettie Marshall Dent Elementary School is located at 37840 New Market Turner Road, Mechanicsville,

MD 20659. A compete survey of key components for this school including, but not limited to the HVAC

system, lighting, communication system upgrades, flooring, and fixtures will be required. This study shall

recommend corrections for all deficiencies noted as well as provide cost estimates for corrections for

each deficiency. The HVAC system was installed in 1992. A transfer switch to allow for large roll-off

generators to power essential portions of the building and an underground fuel tank will be considered

as part of this study.

SECTION III: PROPOSED PROJECTS

This Request for Technical Proposals applies only to Mechanicsville Elementary School and Lettie

Marshall Dent Elementary School – Modernization Feasibility Study.

SECTION IV: EVALUATION AND SELECTION PROCEDURES

A. General

The selection of an A/E is a quality based selection process. The selection of the firm will be based on

all the information received including Technical Proposals. This procurement includes the following

steps:

1. Pre-qualification;

2. Expression of Interest;

3. Submission of Technical Proposals;

4. Evaluation by Selection Committee of Technical Proposals;

5. Short-List of Firms Selected;

6. Final Ranking of Proposal, A/E Selection;

7. Submission of Price Proposal;

8. Final Negotiations.

The SMCPS will not consider modifications to the terms and conditions of its standard contract

which is attached as Appendix A.

B. Technical Proposal Requirements

This proposal should be prepared in a clear and precise manner. It should address all appropriate

points of this RFP. Keep the information brief, SMCPS values quality of information, not quantity. The

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firm is free to choose the format that best suits the information provided. However, failure to provide

the specific information requested herein may result in the technical proposal being determined non-

responsive. Minor irregularities in proposals that are immaterial or inconsequential in nature may be

cured or waived whenever it is determined to be in the best interest of SMCPS.

1. Letter of Transmittal: Provide a Letter of Transmittal, on the Offeror's business stationery,

which should accompany the proposal. The purpose of this letter is to transmit the proposal;

therefore, it should be brief. The letter must be signed by an individual who is authorized to

bind the firm to all statements, including services and prices, contained in the proposal. Any

Addendum issued for this RFP should be acknowledged in the Letter of Transmittal.

2. Proposed Architectural/Engineering design team personnel. Identify and provide resumes

for key personnel both within the prime firm and within each sub-consultant firm (if used).

The key personnel should include the principal-in-charge of the project and project

manager.

3. Provide client references. References should be for projects completed within the last five

years.

4. Provide three (3) examples of K-12 building modernization projects that the

Architect/Engineer believes best displays the capacity of the firm to successfully provide

services and expertise required. The project examples provided must be from completed

projects. Provide background data on these projects, including personnel from the firm

who were involved and a description of their role. The information will be treated with the

strictest confidentiality. The data requested are:

a) a description of the project size, character and extent of deficiencies corrected,

b) completion date and total project cost;

c) scope of services provided,

d) contact information for the owner's representative.

5. Provide an example of a previously completed Feasibility Study for a K-12 project. The Study

should include at least one component related to this RFP.

6. Provide organizational diagram or chart showing responsibilities of the design team and

consultants.

7. Provide a delivery plan identifying the recommended approach including durations and

milestones for completing the feasibility study. The plan should include project

commencement, assessment of existing conditions, developing feasibility study

components, draft report submission and final report submission.

8. Provide any information that the design firm believes will enhance the evaluation of the

firm.

9. Provide a completed and signed copy of the Contract Affidavit which is appended to this

RFP in Appendix B.

10. Provide a completed and signed copy of the Sex Offender Certification which is appended

to this RFP in Appendix C.

11. Provide a completed and signed copy of the Architect/Engineer Qualifications Standard

Form 330 which is appended to this RFP in Appendix D.

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12. The Architect/Engineer must have a completed, current Contractor Qualification

Questionnaire (Appendix E) on file with this office at the time of this proposal

submission.

C. Technical Proposal Evaluation

1. The Selection Committee will review each technical proposal and evaluate it on its merits.

Criteria to be evaluated will include, but not be limited to the Offeror’s a) Understanding and

ability to provide the range of feasibility study services required; b) Prior firm experience with

similar projects; c) Management and technical skills of key personnel.

2. Failure of the Offeror's proposal to provide all of the mandatory feature requirements as

contained within the RFP will normally disqualify an Offeror's proposal as non-responsive. Minor

irregularities in proposals that are immaterial or inconsequential in nature may be cured or

waived whenever it is determined to be in the best interest of SMCPS. Any Offeror whose

proposal is disqualified based on a determination by the Selection Committee that it is non-

responsive will be notified by letter following completion of the evaluation of all technical

proposals.

3. A short list of three (3) firms will be selected. An interview or final presentation may be

conducted. The top ranked firm(s) will be required to submit a fee proposal for review. If the

top ranking firm and SMCPS agree to the fee proposal and the scope of services, a contract

to proceed will be awarded. If an agreement cannot be reached, the next highest ranking

firm will be contacted.

(End of Section)

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SECTION V: APPENDICES

Appendix A. Sample Agreement Between Owner and Architect/Engineer

Appendix B. Contract Affidavit

Appendix C. Sex Offender Certification

Appendix D. Architect/Engineer Qualifications Standard Form 330

Appendix E. Contractor Qualification Questionnaire

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APPENDIX A SAMPLE AGREEMENT

AGREEMENT BETWEEN OWNER AND ARCHITECT/ENGINEER

This Agreement, made as of this ___ day of ___________, ______, between the Board of Education of St.

Mary’s County, (hereinafter referred to as “the Owner”) and _________________________________

(hereinafter referred to as “the Architect/Engineer”), for the rendition of a Feasibility Study as an

independent authority, for the Modernization of Mechanicsville Elementary School and Lettie Marshall

Dent Elementary School (hereinafter referred to as “the Project”).

WHEREAS, the County of St. Mary’s, Maryland has provided funds for public school improvements;

and

WHEREAS, the Architect/Engineer has been fully informed as to the scope of the Project and having

represented itself to be professionally qualified and sufficiently experienced to render the professional

services as detailed herein, having submitted its Contractor Qualifications Questionnaire, Appendix E

dated __________, upon which Contractor Qualification Questionnaire the Owner relies on as indication

of the Architect/Engineer’s ability to satisfactorily perform the professional services covered by this

Agreement.

NOW THEREFORE, in consideration of the mutual promises, premises, and covenants contained herein,

the Owner and the Architect/Engineer do hereby agree as follows:

I. The aforesaid WHEREAS provisions are incorporated herein and form a part of this

Agreement.

II. The Architect/Engineer shall provide professional services for the Project in accordance

with the Terms and Conditions of this Agreement.

III. The Owner shall compensate the Architect/Engineer, in accordance with the Terms and

Conditions of this Agreement, and as follows:

a. FOR THE ARCHITECT/ENGINEER’s BASIC SERVICES, as described in Section 1.1, basic

compensation shall be computed in accordance with the Fee Proposal, which is

attached hereto and made a part of this Agreement.

b. FOR THE ARCHITECT/ENGINEER’s REIMBURSEABLE EXPENSES, compensation has been

fixed per Section 1.1.

ARTICLE 1 – ARCHITECT/ENGINEER SERVICES

1.1 The Architect/Engineer Services are fully described in the proposal for professional services,

dated __________________, and are hereby incorporated and appended to this agreement.

ARTICLE 2 - THE OWNER’S RESPONSIBILITIES

2.1 The Owner shall provide reasonably detailed information, including architectural and

engineering program, regarding its requirements for this Project.

2.2 The Owner shall designate, when necessary, a representative authorized to act in his behalf

with respect to the Project. The Owner or owner’s representative shall examine documents

submitted by the Architect/Engineer and shall render decisions pertaining thereto promptly, to

avoid unreasonable delay in the progress of the Architect/Engineer’s work.

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2.3 If the Owner observes or otherwise becomes aware of any fault or defect in the Project or of

Architect/Engineer’s non-conformance with the Contract Documents, he shall give prompt

written notice thereof to the Architect/Engineer.

2.4 The Owner shall furnish information required to the A/E as expeditiously as necessary for the

orderly progress of the Work.

ARTICLE 3 – CONSTRUCTION COST

3.1 A Cost Analysis prepared by the A/E represents its best judgement as a design professional

familiar with the construction history. It is recognized, however, that neither the A/E nor the

Owner has any control over the Contractor’s methods of determining bid prices, or over

competitive bidding or market conditions. Accordingly, the A/E cannot and does not

guarantee that bids will not vary from any Costs Analysis or other cost estimate prepared by it.

A preliminary budget will be developed using square foot building costs and additional

necessary project costs for construction, phasing, equipment, fees, contingency, etc.

ARTICLE 4 - PERSONNEL EXPENSE

4.1 Direct Personnel Expense of employees engaged on the Project by the Architect/Engineer

includes architects, engineers, designers, job captains, draftsmen, specification writers, typists,

in consultation, research and design, in producing Drawings, Specifications and other

documents pertaining to the Project, and in providing services during construction at the site, if

applicable.

4.2 Direct Personnel Expense includes costs of salaries including mandatory employee’s taxes only,

and excludes benefits such as insurance, pensions, vacations, sick leave, holidays and similar

benefits.

ARTICLE 5 - REIMBURSABLE EXPENSES

5.1 The Architect/Engineer has anticipated expenses for reproduction and transmittal of

documents, travel, and other miscellaneous expenses. These expenses shall be fixed and

compensated at a lump sum value as provided in Article 1.

ARTICLE 6 - PAYMENTS TO THE ARCHITECT/ENGINEER

6.1 Payments on account of the Architect/Engineer’s Services shall be invoiced to and approved

by the Owner.

6.2 Payments which are not in dispute and are due the Architect/Engineer under this Agreement

shall bear interest at the legal rate commencing sixty (60) days after the date of billing.

6.3 The Owner shall not be responsible to pay, and the Architect/Engineer shall not be entitled to

receive, any compensation for services which are required as a result of the errors, omissions or

negligence of the Architect/Engineer or its consultants, or as a result of the Architect/Engineer’s

willful misconduct or failure to perform in accordance with the terms of this Agreement. The

Owner shall be entitled to withhold payments which may otherwise be due under the terms of

this Agreement in the event the Owner sustains any costs, expenses or other damages as result

of the errors, omissions or negligence of the Architect/Engineer or its consultants, or as a result

of the Architect/Engineer’s willful misconduct or failure to perform in accordance with the terms

of this Agreement. The Architect/Engineer will be responsible, at no cost to the Owner, for

correcting documents exhibiting design errors. The Architect/Engineer will not be responsible

for the construction cost of corrections, except those associated with gross negligence, willful

misconduct or performance not in accordance with the standard of care for an

Architect/Engineer for the type of Project to be addressed under this Agreement.

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6.4 If the scope of work is expanded, the Architect/Engineer fee will be proportionally increased.

ARTICLE 7 – ARCHITECT/ENGINEER ACCOUNTING RECORDS

7.1 Records of the Architect/Engineer’s Direct Personnel, Consultant and Reimbursable Expenses

pertaining to the Project, and records of accounts between the Owner and Contractor, shall

be kept on a generally recognized and accepted accounting basis and shall be available to

the Owner or his authorized representative at mutually convenient times.

ARTICLE 8 - TIME FOR PERFORMANCE

8.1 Time is of the essence under this Agreement. The Architect/Engineer’s services shall be

performed as expeditiously as possible, and as is consistent with professional care and skill and

the orderly progress of the Work.

ARTICLE 9 - INSURANCE

9.1 Architect/Engineer shall maintain at his own expense, and shall require all its consultants to

maintain the following minimum insurance coverage, which insurance shall be placed with

insurance companies rated at least A- by Best’s Key Rating Guide, which insurance shall

incorporate a provision requiring the giving of written notice to the Owner at least thirty (30)

days prior to the cancellation, non-renewal or material modification of any such policies as

evidenced by return receipt of United States Certified Mail:

a. Professional Liability Insurance in the amount of one million dollars ($1,000,000.00)

(including contractual liability coverage with all coverage retroactive to the earlier of

the date of this Agreement or the commencement of Architect/Engineer’s services in

relation to the Project) with coverage to be maintained for a minimum period of three

(3) years after the date of final payment hereunder.

b. Comprehensive General Liability Insurance (including broad-form contractual liability

and completed operations, explosion, and collapse coverage) in the amount of two

million dollars ($2,000,000.00).

c. Comprehensive Automobile Liability Insurance, including hired and non-owned

vehicles, if any, in the amount of one million dollars ($1,000,000.00).

d. Workmen’s Compensation Insurance in the amounts required by statue.

Architect/Engineer shall, upon request, submit valid certificates in form and substance

satisfactory to Owner evidencing the existence of the foregoing insurance policies and

copies of the policies, together with the certificates of insurance and copies of the policies

of Architect/Engineer’s consulting engineers, including any mandatory riders thereto. If

the Architect/Engineer fails to furnish and maintain the insurance required herein, the

Owner may purchase such insurance on behalf of the Architect/Engineer, and the

Architect/Engineer shall pay the cost thereof to the Owner upon demand and shall furnish

to the Owner any information needed to obtain such insurance.

ARTICLE 10 - TERMINATION OF AGREEMENT

10.1 This Agreement may be terminated by either party upon twenty-four (24) hours written notice

should the other party fail substantially to perform in accordance with its terms through no fault

of the party initiating the termination. In the event the Agreement is terminated by the Owner

due to the default of the Architect/Engineer, any amount the Architect/Engineer may

otherwise be entitled to receive as compensation for Basic or Additional Services shall be

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reduced by any costs, damage or expenses incurred by the Owner as a result of such

termination.

10.2 In addition to the right to terminate set forth in paragraph 10.1, this Agreement may also be

terminated by the Owner in its sole discretion at any time, without cause and for any reason,

including the Owner’s own convenience, upon not less than twenty-four (24) hours written

notice to the Architect/Engineer. In the case of such termination, the Architect/Engineer shall

be entitled to payment for services properly provided in accordance with this Agreement prior

to the effective date of such termination, and for any costs directly related to such termination.

Such payments shall be limited to:

a. Payment of the Architect/Engineer’s fees pro-rated to the effective date of termination;

b. Payment of the Architect/Engineer’s actual reimbursable expenses incurred prior to the

effective date of termination, and;

c. Payment of the Architect/Engineer’s actual reasonable costs and expenses of

termination including costs of terminating the Architect/Engineer’s consultants.

The Architect/Engineer shall not be entitled to anticipated fees, profits or overhead on

work or services which have not been performed prior to the effective date of termination.

In the event that the Owner terminates the Architect/Engineer for default and such

termination is subsequently determined to be a wrongful termination, the parties agree

that such termination shall be deemed to be converted to a termination of convenience

and the Architect/Engineer’s recovery shall be limited to sums allowable for such a

termination under this subparagraph.

ARTICLE 11 - OWNERSHIP OF DOCUMENTS

11.1 All documents which are prepared by the Architect/Engineer and form a part of the services

under this Agreement shall, upon completion, become the property of the Owner. The

Architect/Engineer shall be responsible for protection and/or replacement of any Contract

Documents in its possession. The Owner shall receive all original drawings and the

Architect/Engineer shall retain a reproducible copy. All such documents are not to be used by

the Owner on any other Project unless the Owner, prior to such use, executes and delivers to

the Architect/Engineer an agreement in writing, absolving, releasing, indemnifying and saving

the Architect/Engineer harmless of any such use; or in the alternative by providing the

Architect/Engineer appropriate compensation and the right and opportunity to determine the

feasibility and proprietary of any such intended use. In the event of termination of the

Architect/Engineer by the Owner, the Owner, shall, without liability or additional compensation

to the Architect/Engineer, have full authority to utilize all documents provided by the

Architect/Engineer to complete the Project.

ARTICLE 12 - INDEMNIFICATION

12.1 To the fullest extent permitted by law, the Architect/Engineer shall indemnify and hold the

Owner harmless against any judgment, actions, causes of action, or damages or whatever kind

(whether personal injury, property damage, or otherwise, including consequential damages),

and all costs, expenses, losses, attorney’s fees and other damages of any kind, arising out of or

resulting in whole or in part from any of the Architect/Engineer’s work or services under this

Agreement, including but not limited to all claims, actions, causes of action and damages

arising out of any errors, omissions, negligence or willful misconduct on the part of the

Architect/Engineer of any of its consultants, and any breach of this Agreement with the

Architect/Engineer.

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ARTICLE 13 - SUCCESSORS AND ASSIGNS

13.1 The Owner and the Architect/Engineer each binds itself, its partners (if any), successors, assigns

and legal representatives to the other party to this Agreement and to the partners (if any),

successors, assigns and legal representatives of such other party with respect to all covenants

of this Agreement. Neither the Owner nor the Architect/Engineer shall assign, sublet or transfer

any interest in this Agreement without the written consent of the other.

ARTICLE 14 - DISPUTE RESOLUTION

14.1 Any disputes which cannot be resolved by agreement between the Architect/Engineer and

the Owner shall be resolved through litigation in the State Courts of St. Mary’s County, Maryland.

ARTICLE 15 - EXTENT OF AGREEMENT

15.1.1 This Agreement represents the entire and integrated Agreement between the Owner and the

Architect/Engineer and supersedes all prior negotiations, representations or agreements, either

written or oral. This Agreement may be amended only by written instrument signed by both the

Owner and the Architect/Engineer.

ARTICLE 16 - GOVERNING LAW

16.1 Unless otherwise specified, this Agreement shall be governed by the laws in the State of

Maryland, and shall be constructed without regard to any rule or presumption of law requiring

construction against the party causing it to be crafted.

ARTICLE 17 - CIVIL RIGHTS

17.1 It is understood that the provisions of Title VI of the Civil Rights Act of 1968 are hereby included

in this Agreement to the end that no person in the United States shall, on the grounds of race,

color or national origin, be excluded from participation in, be denied the benefits, of, or

otherwise be subjected to discrimination under this Agreement. It is further understood that the

provisions of Article 49B, Section 14 to 20, (Discrimination in Employment) of the Annotated

Code of Maryland, 1991 Edition, and as may be amended from time to time, are incorporated

by reference and are made a part of this Agreement.

ARTICLE 18 - OTHER CONDITIONS

18.1 The Architect/Engineer represents and warrants to the Owner that is financially solvent and has

sufficient knowledge, experience, skill and manpower to perform all of its work and obligations

under this Agreement expeditiously and in accordance with the professional standard of care

applicable under the circumstances, given the scope and expense of the Project.

18.2 The Owner’s approval and/or failure to object to the Architect/Engineer’s selection of its

consultants, principal representative(s) and full time project representative (if applicable) shall

not make the Owner responsible for work or services of such individuals or entities, and shall not

create any contractual relationship between the Owner and any such individuals or entities.

The Architect/Engineer shall be solely responsible for the payment of such individuals or entities,

and shall remain liable and responsible to the Owner for the work or any errors or omissions of

such individuals or entities. The Owner’s approval and/or failure to object to the

Architect/Engineer’s selection of such individual or entities shall not constitute a waiver of the

Owner’s right under this Agreement or at law, and shall not relieve the Architect/Engineer or its

responsibilities under this Agreement.

18.3 The Owner’s approval, acceptance, use of or payment for all or any part of the

Architect/Engineer’s services hereunder or of the Project itself shall not constitute a waiver of

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the Owner’s rights under this Agreement or at law, including its rights to assert claims for errors,

omissions or deficiencies in the Architect/Engineer’s performance hereunder. Approval by the

Owner of any drawings, specifications, bid packages, documents, or other work prepared by

the Architect/Engineer under its Agreement shall not relieve the Architect/Engineer of its

responsibilities under this Agreement including its responsibility for the design of the Project.

18.4 In the event the Owner or Architect/Engineer employs counsel and/or incurs other costs or

expenses to enforce this Agreement or any of the provisions hereof, to institute suite or pursue

a claim, to recover damages for breach of this Agreement, to collect amounts to which it is

entitled under this Agreement, or to otherwise protect its interests in any subsequent matter in

dispute arising under this Agreement, the prevailing party shall be entitled to recover all

reasonable attorney’s fees, court costs or other charges or expenses expended or incurred

herein.

18.5 Each party acknowledges that this Agreement has been fully read and understands the terms

of this Agreement, and has had the opportunity to consult with counsel in the review and

negotiation of this Agreement, and further represents that is has authorized the individual

executing this Agreement to do so on its behalf to be legally bound thereby.

This Agreement is executed under seal as of the day and year written and through the parties’

undersigned authorized representative.

18.6 Owner makes no representations regarding the amount or type of services, if any, that Services

Provider will be asked to provide to Owner during the term(s) of this Agreement. It is expressly

understood that the Owner is under no obligation to request any services from Services Provider

and no minimum amount of work is required or contemplated under this Agreement. All service

requests will be made by the Owner on an as-needed basis, subject to future agreement on

the scope of the work and the fee.

OWNER - Board of Education of St. Mary’s County ARCHITECT/ENGINEER –

______________________________________________

Dr. J. Scott Smith

Superintendent of Schools

_________________________________________

Name

Title

______________________________________________

Date Executed

_________________________________________

Date Executed

______________________________________________

Witness for the Owner

_______________________________________________

Notary Public (Seal)

My commission expires:

____________________________________

_________________________________________

Witness for the Architect/Engineer

_________________________________________

Notary Public (Seal)

My commission expires:

____________________________________

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APPENDIX B CONTRACT AFFIDAVIT

MARYLAND STATE PROCUREMENT ARTICLE 21, SECTION 3-405:

VENDOR/CONTRACTOR DISQUALIFICATION - BRIBERY.

A person convicted for bribery, attempted bribery, or conspiracy to bribe shall be disqualified from

entering into a Contract with any county or other subdivision of the State. Every business entity upon

submitting a bid or otherwise applying for a Contract shall submit an affidavit stating whether it, its

officers, directors, or partners, or its employees have been convicted of bribery, attempted bribery, or

conspiracy to bribe under the laws of any State or Federal government.

__________________________________ affirms that it is in full compliance with the aforementioned (COMPANY NAME)

Maryland State Procurement Article 21, Section 3-405.

STATEMENT OF NON-COLLUSION

1. The undersigned affirms that this bid is made without any previous understanding, agreement

or connection with any person, firm or corporation submitting a bid for the same items and/or services

and is, in all respects, fair and without collusion or fraud; and that no member of the Board of Education,

St. Mary’s County Public Schools, the Administrative or Supervisory personnel, or other employees of the

St. Mary’s County Public Schools will benefit from the award of this bid in violation of Maryland law.

Name of Authorized Company Representative: ______________________________________________ (PRINT OR TYPE NAME)

Signature of Authorized Company Representative: ___________________________________________

To be completed by an authorized company representative and a Notary Public:

Dated at ____________________________________________ this ____________________________ day of

___________________________ 20 ________.

Name of Organization __________________________________

By ________________________________________________________________________ being duly sworn (NAME)

deposed and says that he/she is the ______________________________________________________ of (OFFICER)

_________________________________, and that all the foregoing statements are true and correct. (CONTRACTING FIRM NAME)

Subscribed and sworn before me this _______________________ day of ______________, 20_______.

Notary Public: _____________________________________

My Commission Expires: _______________

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APPENDIX C SEX OFFENDER CERTIFICATION

SEX OFFENDER CERTIFICATION

In conjunction with the submission of its bid, and as a condition precedent to the award of a

Contract by the Board of Education of St. Mary’s County, the undersigned bidder, by and through its

authorized undersigned representative, acknowledges the following provisions of the Criminal

Procedure Article of the Annotated Code of Maryland relating to the employment of registered sex

offenders, and certifies as follows:

Annotated Code Criminal Procedure Article Provisions

§ 11-722. Entry onto school or day care property prohibited.

(c) Employment of registrants at schools prohibited. -- A person who enters into a contract with a

county board of education or a nonpublic school may not knowingly employ an individual to work at

a school if the individual is a registrant. (d) Violations; penalty. -- A person who violates this section is

guilty of a misdemeanor and on conviction is subject to imprisonment not exceeding 5 years or a fine

not exceeding $ 5,000 or both.

Certification

The undersigned bidder hereby certifies to the Board of Education of St. Mary’s County that no

employee, subcontractor, subcontractor employee, or material supplier that is a registered sex

offender will be allowed to enter onto school system property at any time in the performance of the

work or services for which the contract is awarded.

Name of Individual/Organization (Bidder):____________________________________

(Print or type name)

Name of Authorized Representative: __________________________________________

(Print or type name)

Signature of Authorized Representative: _______________________________________

The aforesaid bidder further acknowledges that it will be the responsibility of all contractors to obtain

similar certifications from all subcontractors, suppliers and vendors delivering materials, equipment or

supplies to school system property, and/or performing work or services on school system property,

and to monitor adherence to this requirement. In the event that the Owner determines that a

registered sex offender has entered upon school property for a delivery of materials, equipment or

supplies and/or for the performance of work or services under the contract, such will be grounds for

termination of the contract.

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APPENDIX D ARCHITECT/ENGINEER QUALIFICATIONS STANDARD FORM 330

Please include the following document (Standard Form 330) with your Technical

Proposal.

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Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0157. We estimate that it will take 29 hours (25 hours for part 1 and 4 hours for Part 2) to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.

PURPOSE

Federal agencies use this form to obtain information from architect-engineer (A-E) firms about their professional qualifications. Federal agencies select firms for A-E contracts on the basis of professional qualifications as required by 40 U.S.C. chapter 11, Selection of Architects Engineers, and Part 36 of the Federal Acquisition Regulation (FAR).

The Selection of Architects and Engineers statute requires the public announcement of requirements for A-E services (with some exceptions provided by other statutes), and the selection of at least three of the most highly qualified firms based on demonstrated competence and professional qualifications according to specific criteria published in the announcement. The Act then requires the negotiation of a contract at a fair and reasonable price starting first with the most highly qualified firm.

The information used to evaluate firms is from this form and other sources, including performance evaluations, any additional data requested by the agency, and interviews with the most highly qualified firms and their references.

GENERAL INSTRUCTIONS

Part I presents the qualifications for a specific contract.

Part II presents the general qualifications of a firm or a specific branch office of a firm. Part II has two uses:

1. An A-E firm may submit Part II to the appropriate central,regional or local office of each Federal agency to be kept on file. A public announcement is not required for certain contracts, and agencies may use Part II as a basis for selecting at least three of the most highly qualified firms for discussions prior to requesting submission of Part I. Firms are encouraged to update Part II on file with agency offices, as appropriate, according to FAR Part 36. If a firm has branch offices, submit a separate Part II foreach branch office seeking work.

2. Prepare a separate Part II for each firm that will be part ofthe team proposed for a specific contract and submitted with Part I. If a firm has branch offices, submit a separate Part II for eachbranch office that has a key role on the team.

INDIVIDUAL AGENCY INSTRUCTIONS

Individual agencies may supplement these instructions. For example, they may limit the number of projects or number of pages submitted in Part I in response to a public announcement for a particular project. Carefully comply with any agency instructions when preparing and submitting this form. Be as concise as possible and provide only the information requested by the agency.

DEFINITIONS

Architect-Engineer Services: Defined in FAR 2.101.

Branch Office: A geographically distinct place of business or subsidiary office of a firm that has a key role on the team.

Discipline: Primary technical capabilities of key personnel, as evidenced by academic degree, professional registration, certification, and/or extensive experience.

Firm: Defined in FAR 36.102.

Key Personnel: Individuals who will have major contract responsibilities and/or provide unusual or unique expertise.

SPECIFIC INSTRUCTIONS

Part I - Contract-Specific Qualifications

Section A. Contract Information.

1. Title and Location. Enter the title and location of thecontract for which this form is being submitted, exactly as shown in the public announcement or agency request.

2. Public Notice Date. Enter the posted date of the agency'snotice on the Federal Business Opportunity website (FedBizOpps), other form of public announcement or agency request for this contract.

3. Solicitation or Project Number. Enter the agency'ssolicitation number and/or project number, if applicable, exactly as shown in the public announcement or agency request for this contract.

Section B. Architect-Engineer Point of Contact.

4-8. Name, Title, Name of Firm, Telephone Number, Fax(Facsimile) Number and E-mail (Electronic Mail) Address. Provide information for a representative of the prime contractor or joint venture that the agency can contact for additional information.

AUTHORIZED FOR LOCAL REPRODUCTION STANDARD FORM 330 (REV. 8/2016) PAGE 1 OF INSTRUCTIONS Prescribed by GSA - FAR (48 CFR) 53.236-2(b)

ARCHITECT-ENGINEER QUALIFICATIONS OMB Control Number: 9000-0157 Expiration Date: 12/31/2020

APPENDIX D

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Section C. Proposed Team.

9-11. Firm Name, Address, and Role in This Contract.

Provide the contractual relationship, name, full mailing address, and a brief description of the role of each firm that will be involved in performance of this contract. List the prime contractor or joint venture partners first. If a firm has branch offices, indicate each individual branch office that will have a key role on the team. The named subcontractors and outside associates or consultants must be used, and any change must be approved by the contracting officer. (See FAR Part 52 Clause "Subcontractors and Outside Associates and Consultants (Architect-Engineer Services)"). Attach an additional sheet in the same format as Section C if needed.

Section D. Organizational Chart of Proposed Team.

As an attachment after Section C, present an organizational

chart of the proposed team showing the names and roles of all key personnel listed in Section E and the firm they are associated with as listed in Section C.

Section E. Resumes of Key Personnel Proposed for this

Contract.

Complete this section for each key person who will participate in this contract. Group by firm, with personnel of the prime contractor or joint venture partner firms first. The following blocks must be completed for each resume:

12. Name. Self-explanatory.

13. Role in this contract. Self-explanatory.

14. Years Experience. Total years of relevant experience

(block 14a), and years of relevant experience with current firm, but not necessarily the same branch office (block 14b).

15. Firm Name and Location. Name, city and state of the

firm where the person currently works, which must correspond with one of the firms (or branch office of a firm, if appropriate) listed in Section C.

16. Education. Provide information on the highest relevant

academic degree(s) received. Indicate the area(s) of specialization for each degree.

17. Current Professional Registration. Provide information

on current relevant professional registration(s) in a State or possession of the United States, Puerto Rico, or the District of Columbia according to FAR Part 36.

18. Other Professional Qualifications. Provide information

on any other professional qualifications relating to this contract, such as education, professional registration, publications, organizational memberships, certifications, training, awards, and foreign language capabilities.

19. Relevant Projects. Provide information on up to five

projects in which the person had a significant role that demonstrates the person's capability relevant to her/his proposed role in this contract. These projects do not necessarily have to be any of the projects presented in Section F for the project team if the person was not involved in any of those projects or the person worked on other projects that were more relevant than the team projects in Section F. Use the check box provided to indicate if the project was performed with any office of the current firm. If any of the professional services or construction projects are not complete, leave Year Completed blank and indicate the status in Brief Description and Specific Role (block (3)).

Section F. Example Projects Which Best Illustrate Proposed

Team's Qualifications for this Contract.

Select projects where multiple team members worked together, if possible, that demonstrate the team's capability to perform work similar to that required for this contract. Complete one Section F for each project. Present ten projects, unless otherwise specified by the agency. Complete the following blocks for each project:

20. Example Project Key Number. Start with "1" for the first

project and number consecutively.

21. Title and Location. Title and location of project or contract. For an indefinite delivery contract, the location is the geographic scope of the contract.

22. Year Completed. Enter the year completed of the

professional services (such as planning, engineering study, design, or surveying), and/or the year completed of construction, if applicable. If any of the professional services or the construction projects are not complete, leave Year Completed blank and indicate the status in Brief Description of Project and Relevance to this Contract (block 24).

23a. Project Owner. Project owner or user, such as a

government agency or installation, an institution, a corporation or private individual.

23b. Point of Contact Name. Provide name of a person

associated with the project owner or the organization which contracted for the professional services, who is very familiar with the project and the firm's (or firms') performance.

23c. Point of Contact Telephone Number. Self-explanatory.

24. Brief Description of Project and Relevance to this

Contract. Indicate scope, size, cost, principal elements and special features of the project. Discuss the relevance of the example project to this contract. Enter any other information requested by the agency for each example project.

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25. Firms from Section C Involved with this Project. Indicate which firms (or branch offices, if appropriate) on the project team were involved in the example project, and their roles. List in the same order as Section C.

Section G. Key Personnel Participation in Example Projects.

This matrix is intended to graphically depict which key

personnel identified in Section E worked on the example projects listed in Section F. Complete the following blocks (see example below).

26. and 27. Names of Key Personnel and Role in this

Contract. List the names of the key personnel and their proposed roles in this contract in the same order as they appear in Section E.

28. Example Projects Listed in Section F. In the column

under each project key number (see block 29) and for each key person, place an "X" under the project key number for participation in the same or similar role.

29. Example Projects Key. List the key numbers and titles of the example projects in the same order as they appear in Section F.

Section H. Additional Information.

30. Use this section to provide additional information

specifically requested by the agency or to address selection criteria that are not covered by the information provided in Sections A-G.

Section I. Authorized Representative.

31. and 32. Signature of Authorized Representative and

Date. An authorized representative of a joint venture or the prime contractor must sign and date the completed form. Signing attests that the information provided is current and factual, and that all firms on the proposed team agree to work on the project. Joint ventures selected for negotiations must make available a statement of participation by a principal of each member of the joint venture.

33. Name and Title. Self-explanatory.

SAMPLE ENTRIES FOR SECTION G (MATRIX)

26. NAMES OF KEY PERSONNEL

(From Section E, Block 12)

27. ROLE IN THIS CONTRACT

(From Section E, Block 13)

28. EXAMPLE PROJECTS LISTED IN SECTION F (Fill in "Example Projects Key" section below first, before completing table. Place "X" under project key number for

participation in same or similar role.) 1 2 3 4 5 6 7 8 9 10

Jane A. Smith

Chief Architect X

X

Joseph B. Williams

Chief Mechanical Engineer X X X X

Tara C. Donovan

Chief Electricial Engineer X X

X

29. EXAMPLE PROJECTS KEY

N UMBER TITLE OF EXAMPLE PROJECT (From Section F) NUMBER TITLE OF EXAMPLE PROJECT (From Section F)

1 Federal Courthouse, Denver, CO 6 XYZ Corporation Headquarters, Boston, MA

2 Justin J. Wilson Federal Building, Baton Rouge, LA

7 Founder's Museum, Newport, RI

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Part II - General Qualifications

See the "General Instructions" on page 1 for firms with branch offices. Prepare Part II for the specific branch office seeking work if the firm has branch offices.

1. Solicitation Number. If Part II is submitted for a specific

contract, insert the agency's solicitation number and/or project number, if applicable, exactly as shown in the public announcement or agency request.

2a-2e. Firm (or Branch Office) Name and Address. Self-

explanatory.

3. Year Established. Enter the year the firm (or branch office, if appropriate) was established under the current name.

4. Unique Entity Identifier. Insert the unique entity identifier

issued by the entity designated at SAM. See FAR part 4.6.

5. Ownership.

a. Type. Enter the type of ownership or legal structure of the firm (sole proprietor, partnership, corporation, joint venture, etc.).

b. Small Business Status. Refer to the North American

Industry Classification System (NAICS) code in the public announcement, and indicate if the firm is a small business according to the current size standard for that NAICS code (for example, Engineering Services (part of NAICS 541330), Architectural Services (NAICS 541310), Surveying and Mapping Services (NAICS 541370)). The small business categories and the internet website for the NAICS codes appear in FAR part 19. Contact the requesting agency for any questions. Contact your local U.S. Small Business Administration office for any questions regarding Business Status.

6a-6c. Point of Contact. Provide this information for a

representative of the firm that the agency can contact for additional information. The representative must be empowered to speak on contractual and policy matters.

7. Name of Firm. Enter the name of the firm if Part II is

prepared for a branch office.

8a-8c. Former Firm Names. Indicate any other previous names for the firm (or branch office) during the last six years. Insert the year that this corporate name change was effective and the associated unique entity identifier. This information is used to review past performance on Federal contracts.

9. Employees by Discipline. Use the relevant disciplines and associated function codes shown at the end of these instructions and list in the same numerical order. After the listed disciplines, write in any additional disciplines and leave the function code blank. List no more than 20 disciplines. Group remaining employees under "Other Employees" in column b. Each person can be counted only once according to his/her primary function. If Part II is prepared for a firm (including all branch offices), enter the number of employees by disciplines in column c(1). If Part II is prepared for a branch office, enter the number of employees by discipline in column c(2) and for the firm in column c(1).

10. Profile of Firm's Experience and Annual Average

Revenue for Last 5 Years. Complete this block for the firm or branch office for which this Part II is prepared. Enter the experience categories which most accurately reflect the firm's technical capabilities and project experience. Use the relevant experience categories and associated profile codes shown at the end of these instructions, and list in the same numerical order. After the listed experience categories, write in any unlisted relevant project experience categories and leave the profile codes blank. For each type of experience, enter the appropriate revenue index number to reflect the professional services revenues received annually (averaged over the last 5 years) by the firm or branch office for performing that type of work. A particular project may be identified with one experience category or it may be broken into components, as best reflects the capabilities and types of work performed by the firm. However, do not double count the revenues received on a particular project.

11. Annual Average Professional Services Revenues of Firm

for Last 3 Years. Complete this block for the firm or branch office for which this Part II is prepared. Enter the appropriate revenue index numbers to reflect the professional services revenues received annually (averaged over the last 3 years) by the firm or branch office. Indicate Federal work (performed directly for the Federal Government, either as the prime contractor or subcontractor), non-Federal work (all other domestic and foreign work, including Federally-assisted projects), and the total. If the firm has been in existence for less than 3 years, see the definition for "Annual Receipts" under FAR 19.101.

12. Authorized Representative. An authorized

representative of the firm or branch office must sign and date the completed form. Signing attests that the information provided is current and factual. Provide the name and title of the authorized representative who signed the form.

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List of Disciplines (Function Codes)

Code Description Code Description

01 Acoustical Engineer 32 Hydraulic Engineer 02 Administrative 33 Hydrographic Surveyor 03 Aerial Photographer 34 Hydrologist 04 Aeronautical Engineer 35 Industrial Engineer 05 Archeologist 36 Industrial Hygienist 06 Architect 37 Interior Designer 07 Biologist 38 Land Surveyor 08 CADD Technician 39 Landscape Architect 09 Cartographer 40 Materials Engineer 10 Chemical Engineer 41 Materials Handling Engineer 11 Chemist 42 Mechanical Engineer 12 Civil Engineer 43 Mining Engineer 13 Communications Engineer 44 Oceanographer 14 Computer Programmer 45 Photo Interpreter 15 Construction Inspector 46 Photogrammetrist 16 Construction Manager 47 Planner: Urban/Regional 17 Corrosion Engineer 48 Project Manager 18 Cost Engineer/Estimator 49 Remote Sensing Specialist 19 Ecologist 50 Risk Assessor 20 Economist 51 Safety/Occupational Health Engineer 21 Electrical Engineer 52 Sanitary Engineer 22 Electronics Engineer 53 Scheduler 23 Environmental Engineer 54 Security Specialist 24 Environmental Scientist 55 Soils Engineer 25 Fire Protection Engineer 56 Specifications Writer 26 Forensic Engineer 57 Structural Engineer 27 Foundation/Geotechnical Engineer 58 Technician/Analyst 28 Geodetic Surveyor 59 Toxicologist 29 Geographic Information System Specialist 60 Transportation Engineer 30 Geologist 61 Value Engineer 31 Health Facility Planner 62 Water Resources Engineer

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STANDARD FORM 330 (REV. 8/2016) PAGE 6 OF INSTRUCTIONS

List of Experience Categories (Profile Codes)

Code Description Code Description A01 A02

A03 A04 A05 A06 A07 A08 A09 A10 A11 A12

B01 B02

C01 C02 C03

Acoustics, Noise Abatement Aerial Photography; Airborne Data and Imagery Collection and Analysis Agricultural Development; Grain Storage; Farm Mechanization Air Pollution Control Airports; Navaids; Airport Lighting; Aircraft Fueling Airports; Terminals and Hangars; Freight Handling Arctic Facilities Animal Facilities Anti-Terrorism/Force Protection Asbestos Abatement Auditoriums & Theaters Automation; Controls; Instrumentation

Barracks; Dormitories Bridges

Cartography Cemeteries (Planning & Relocation) Charting: Nautical and Aeronautical

E01 E02 E03 E04 E05 E06 E07 E08 E09

E10

E11 E12 E13

F01 F02 F03 F04 F05 F06

Ecological & Archeological Investigations Educational Facilities; Classrooms Electrical Studies and Design Electronics Elevators; Escalators; People-Movers Embassies and Chanceries Energy Conservation; New Energy Sources Engineering Economics Environmental Impact Studies, Assessments or Statements Environmental and Natural Resource Mapping Environmental Planning Environmental Remediation Environmental Testing and Analysis

Fallout Shelters; Blast-Resistant Design Field Houses; Gyms; Stadiums Fire Protection Fisheries; Fish ladders Forensic Engineering Forestry & Forest products

C15 C16 C17 C18

C19

D01 D02 D03 D04 D05 D06 D07 D08

Construction Management Construction Surveying Corrosion Control; Cathodic Protection; Electrolysis Cost Estimating; Cost Engineering and Analysis; Parametric Costing; Forecasting Cryogenic Facilities

Dams (Concrete; Arch) Dams (Earth; Rock); Dikes; Levees Desalinization (Process & Facilities) Design-Build - Preparation of Requests for Proposals Digital Elevation and Terrain Model Development Digital Orthophotography Dining Halls; Clubs; Restaurants Dredging Studies and Design

H01

H02 H03

H04 H05 H06 H07

H08 H09 H10 H11

H12 H13

Harbors; Jetties; Piers, Ship Terminal Facilities Hazardous Materials Handling and Storage Hazardous, Toxic, Radioactive Waste Remediation Heating; Ventilating; Air Conditioning Health Systems Planning Highrise; Air-Rights-Type Buildings Highways; Streets; Airfield Paving; Parking Lots Historical Preservation Hospital & Medical Facilities Hotels; Motels Housing (Residential, Multi-Family; Apartments; Condominiums) Hydraulics & Pneumatics Hydrographic Surveying

C04 Chemical Processing & Storage

C05 Child Care/Development Facilities G01 Garages; Vehicle Maintenance Facilities; C06 Churches; Chapels Parking Decks

C07 Coastal Engineering G02 Gas Systems (Propane; Natural, Etc.) C08 Codes; Standards; Ordinances G03 Geodetic Surveying: Ground and Air-borne C09 C10

Cold Storage; Refrigeration and Fast Freeze Commercial Building (low rise) ; Shopping Centers

G04 Geographic Information System Services: Development, Analysis, and Data Collection

C11 C12

Community Facilities Communications Systems; TV; Microwave

G05 Geospatial Data Conversion: Scanning, Digitizing, Compilation, Attributing, Scribing,

C13 Computer Facilities; Computer Service Drafting

C14 Conservation and Resource Management G06 Graphic Design

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List of Experience Categories (Profile Codes continued)

Code Description Code Description I01

I02

I03

I04

Industrial Buildings; Manufacturing Plants

Industrial Processes; Quality Control

Industrial Waste Treatment

Intelligent Transportation Systems

P09

P10

P11

P12

Product, Machine Equipment Design

Pneumatic Structures, Air-Support Buildings

Postal Facilities

Power Generation, Transmission, Distribution I05 Interior Design; Space Planning P13 Public Safety Facilities I06 Irrigation; Drainage

R01

Radar; Sonar; Radio & Radar Telescopes J01 Judicial and Courtroom Facilities R02 Radio Frequency Systems & Shieldings

L01 Laboratories; Medical Research Facilities R03 Railroad; Rapid Transit

L02 Land Surveying R04 Recreation Facilities (Parks, Marinas, Etc.)

L03 Landscape Architecture R05 Refrigeration Plants/Systems

L04 Libraries; Museums; Galleries R06 Rehabilitation (Buildings; Structures; Facilities) L05 Lighting (Interior; Display; Theater, Etc.) R07 Remote Sensing L06 Lighting (Exteriors; Streets; Memorials; R08 Research Facilities

M01

M02

M03

M04

M05

M06

M07

M08

N01

N02

N03

O01 O02 O03

P01

P02

P03

P04

P05

P06

P07

P08

Athletic Fields, Etc.)

Mapping Location/Addressing Systems

Materials Handling Systems; Conveyors; Sorters

Metallurgy

Microclimatology; Tropical Engineering

Military Design Standards

Mining & Mineralogy

Missile Facilities (Silos; Fuels; Transport)

Modular Systems Design; Pre-Fabricated Structures or Components

Naval Architecture; Off-Shore Platforms

Navigation Structures; Locks

Nuclear Facilities; Nuclear Shielding

Office Buildings; Industrial Parks Oceanographic Engineering Ordnance; Munitions; Special Weapons

Petroleum Exploration; Refining

Petroleum and Fuel (Storage and Distribution)

Photogrammetry

Pipelines (Cross-Country - Liquid & Gas)

Planning (Community, Regional, Areawide and State)

Planning (Site, Installation, and Project)

Plumbing & Piping Design

Prisons & Correctional Facilities

R09

R10

R11

R12

S01

S02

S03

S04

S05

S06

S07

S08

S09

S10

S11

S12

S13

T01

T02 T03 T04 T05 T06

Resources Recovery; Recycling

Risk Analysis

Rivers; Canals; Waterways; Flood Control

Roofing

Safety Engineering; Accident Studies; OSHA Studies

Security Systems; Intruder & Smoke Detection

Seismic Designs & Studies

Sewage Collection, Treatment and Disposal

Soils & Geologic Studies; Foundations

Solar Energy Utilization

Solid Wastes; Incineration; Landfill

Special Environments; Clean Rooms, Etc.

Structural Design; Special Structures

Surveying; Platting; Mapping; Flood Plain Studies

Sustainable Design

Swimming Pools

Storm Water Handling & Facilities

Telephone Systems (Rural; Mobile; Intercom, Etc.) Testing & Inspection Services Traffic & Transportation Engineering Topographic Surveying and Mapping Towers (Self-Supporting & Guyed Systems) Tunnels & Subways

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List of Experience Categories (Profile Codes continued)

Code Description U01

U02

U03

V01

W01

W02

W03

W04

Z01

Unexploded Ordnance Remediation

Urban Renewals; Community Development

Utilities (Gas and Steam)

Value Analysis; Life-Cycle Costing

Warehouses & Depots

Water Resources; Hydrology; Ground Water

Water Supply; Treatment and Distribution

Wind Tunnels; Research/Testing Facilities Design

Zoning; Land Use Studies

STANDARD FORM 330 (REV. 8/2016) PAGE 8 OF INSTRUCTIONS

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2. PUBLIC NOTICE DATE 3. SOLICITATION OR PROJECT NUMBER

ARCHITECT - ENGINEER QUALIFICATIONS

PART I - CONTRACT-SPECIFIC QUALIFICATIONS

A. CONTRACT INFORMATION

1. TITLE AND LOCATION (City and State)

4. NAME AND TITLE

B. ARCHITECT-ENGINEER POINT OF CONTACT

5. NAME OF FIRM

6. TELEPHONE NUMBER 7. FAX NUMBER 8. E-MAIL ADDRESS

C. PROPOSED TEAM (Complete this section for the prime contractor and all key subcontractors.)

(Check)

9. FIRM NAME

10. ADDRESS

11. ROLE IN THIS CONTRACT

PRIM

E

J-V

PAR

TNER

SU

BCO

N-

TRAC

TOR

a.

CHECK IF BRANCH OFFICE

b.

CHECK IF BRANCH OFFICE

c.

CHECK IF BRANCH OFFICE

d.

CHECK IF BRANCH OFFICE

e.

CHECK IF BRANCH OFFICE

f.

CHECK IF BRANCH OFFICE

D. ORGANIZATIONAL CHART OF PROPOSED TEAM (Attached)

AUTHORIZED FOR LOCAL REPRODUCTION STANDARD FORM 330 (REV. 8/2016)

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16. EDUCATION (Degree and Specialization) 17. CURRENT PROFESSIONAL REGISTRATION (State and Discipline)

E. RESUMES OF KEY PERSONNEL PROPOSED FOR THIS CONTRACT (Complete one Section E for each key person.)

12. NAME 13. ROLE IN THIS CONTRACT 14. YEARS EXPERIENCE a. TOTAL b. WITH CURRENT FIRM

15. FIRM NAME AND LOCATION (City and State)

18. OTHER PROFESSIONAL QUALIFICATIONS (Publications, Organizations, Training, Awards, etc.)

19. RELEVANT PROJECTS

a.

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm

b.

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED

PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm

c.

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm

d.

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm

e.

(1) TITLE AND LOCATION (City and State) (2) YEAR COMPLETED

PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

(3) BRIEF DESCRIPTION (Brief scope, size, cost, etc.) AND SPECIFIC ROLE Check if project performed with current firm

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F. EXAMPLE PROJECTS WHICH BEST ILLUSTRATE PROPOSED TEAM'S QUALIFICATIONS FOR THIS CONTRACT

(Present as many projects as requested by the agency, or 10 projects, if not specified. Complete one Section F for each project.)

20. EXAMPLE PROJECT KEY NUMBER

21. TITLE AND LOCATION (City and State) 22. YEAR COMPLETED PROFESSIONAL SERVICES CONSTRUCTION (If applicable)

23. PROJECT OWNER'S INFORMATION

a. PROJECT OWNER b. POINT OF CONTACT NAME c. POINT OF CONTACT TELEPHONE NUMBER

24. BRIEF DESCRIPTION OF PROJECT AND RELEVANCE TO THIS CONTRACT (Include scope, size, and cost)

25. FIRMS FROM SECTION C INVOLVED WITH THIS PROJECT

a.

(1) FIRM NAME (2) FIRM LOCATION (City and State) (3) ROLE

b.

(1) FIRM NAME (2) FIRM LOCATION (City and State) (3) ROLE

c.

(1) FIRM NAME (2) FIRM LOCATION (City and State) (3) ROLE

d.

(1) FIRM NAME (2) FIRM LOCATION (City and State) (3) ROLE

e.

(1) FIRM NAME (2) FIRM LOCATION (City and State) (3) ROLE

f.

(1) FIRM NAME (2) FIRM LOCATION (City and State) (3) ROLE

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STANDARD FORM 330 (REV. 8/2016) PAGE 4

G. KEY PERSONNEL PARTICIPATION IN EXAMPLE PROJECTS

26. NAMES OF KEY PERSONNEL

(From Section E, Block 12)

27. ROLE IN THIS CONTRACT

(From Section E, Block 13)

28. EXAMPLE PROJECTS LISTED IN SECTION F (Fill in "Example Projects Key" section below before completing table.

Place "X" under project key number for participation in same or similar role.) 1 2 3 4 5 6 7 8 9 10

29. EXAMPLE PROJECTS KEY

N UMBER TITLE OF EXAMPLE PROJECT (From Section F) NUMBER TITLE OF EXAMPLE PROJECT (From Section F)

1

6

2

7

3

8

4

9

5

10

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31. SIGNATURE 32. DATE

H. ADDITIONAL INFORMATION

30. PROVIDE ANY ADDITIONAL INFORMATION REQUESTED BY THE AGENCY. ATTACH ADDITIONAL SHEETS AS NEEDED.

I. AUTHORIZED REPRESENTATIVE The foregoing is a statement of facts.

33. NAME AND TITLE

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PART II - GENERAL QUALIFICATIONS

(If a firm has branch offices, complete for each specific branch office seeking work.) 2a. FIRM (or Branch Office) NAME 3. YEAR ESTABLISHED 4. UNIQUE ENTITY IDENTIFIER

2b. STREET 5. OWNERSHIP a. TYPE

2c. CITY 2d. STATE 2e. ZIP CODE

b. SMALL BUSINESS STATUS 6a. POINT OF CONTACT NAME AND TITLE

7. NAME OF FIRM (If Block 2a is a Branch Office)

6b. TELEPHONE NUMBER 6c. E-MAIL ADDRESS

8a. FORMER FIRM NAME(S) (If any) 8b. YEAR ESTABLISHED 8c. UNIQUE ENTITY IDENTIFIER

9. EMPLOYEES BY DISCIPLINE 10. PROFILE OF FIRM'S EXPERIENCE AND ANNUAL AVERAGE REVENUE FOR LAST 5 YEARS

a. Function Code b. Discipline

c. Number of Employees a. Profile Code b. Experience

c. Revenue Index Number

(see below) (1) FIRM (2) BRANCH Other Employees

Total

11. ANNUAL AVERAGE PROFESSIONAL SERVICES REVENUES OF FIRM

FOR LAST 3 YEARS (Insert revenue index number shown at right)

PROFESSIONAL SERVICES REVENUE INDEX NUMBER 1. Less than $100,000 6. $2 million to less than $5 million 2. $100,000 to less than $250,000 7. $5 million to less than $10 million 3. $250,000 to less than $500,000 8. $10 million to less than $25 million 4. $500,000 to less than $1 million 9. $25 million to less than $50 million 5. $1 million to less than $2 million 10. $50 million or greater

a. Federal Work

b. Non-Federal Work

c. Total Work

12. AUTHORIZED REPRESENTATIVE The foregoing is a statement of facts.

c. NAME AND TITLE

STANDARD FORM 330 (REV. 8/2016) PAGE 6

1. SOLICITATION NUMBER (If any)

ARCHITECT-ENGINEER QUALIFICATIONS

a. SIGNATURE b. DATE

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APPENDIX E CONTRACTOR’S QUALIFICATION QUESTIONNAIRE

If you do not have a current Contractor’s Qualification Questionnaire on file with St.

Mary’s County Public Schools, please include the following documents with your

Technical Proposal.

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2020

CONTRACTOR’S QUALIFICATION QUESTIONNAIRE FOR

_______CONSTRUCTION OF PUBLIC SCHOOLS_______

PUBLIC SCHOOL CONSTRUCTION PROGRAM

BOARD OF EDUCATION OF ST. MARY’S COUNTY

This questionnaire is intended as a basis for establishing the qualifications of Contractors for undertaking

construction work under the jurisdiction of the Board of Education of St. Mary’s County Public Schools.

If a Contractor has completed a questionnaire and delivered such to the local education agency having

jurisdiction setting forth his qualifications to the satisfaction of the Superintendent of Schools, he (the

Contractor) will be eligible to receive construction documents for bidding, but may be ineligible to be

considered for a contract. Failure to have a completed qualification questionnaire delivered to St. Mary's

County Public Schools prior to delivery of a bid may result in the rejection of said bid. Certification of

qualification shall be valid for one calendar year only and only for general construction projects, not those

requiring a specific prequalification submission under a multi-step procurement.

I General

a) Legal Title and Address of Organization:

b)

Telephone and Facsimile Numbers :

c)

Website and Email Address for Organization:

d)

Maryland Representative’s Name, Title, Mailing Address and Email Address:

e) Check if: _____Corporation _____Co-Partnership _____Individual

f)

If a Corporation, please state:

Capital Paid in Cash$_____________________ Date of Incorporation:____________________

State in which Incorporated:_____________________________

Name and Title of Principal Officers Date Assuming Position

g) If Co-Partnership, please state:

Date of Organization:_____________________________________

Nature of Partnership: _____General, _____Limited, _____Association

Names and Addresses of Partners (Attach separate sheet if necessary): Age:

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h) If Individual, please state full name and address of Owner:

i) List major items of equipment fully owned by organization, giving approximate value and age.

(If not fully owned, please so state.)

j) Is any member of your organization employed by St. Mary’s County or in any way officially

connected with the Local Government? If yes, please explain.

k) Give name and data about any construction projects you have failed to complete (use

separate sheet if necessary).

l) Has your organization ever been party to any criminal litigation as a result of construction

methods, costs, etc.?______ If yes, please explain.

m) If operating as a General Contractor, has your present or past bonding company ever been

requested to take action against you as a result of performance or payment related issues?

__________. If yes, please explain.

II. Financial

a) Give the value of all construction equipment fully owned by your organization.

$_____________________________

b) Give the value of the total assets of the organization (including equipment value in II.a above):

$_____________________________

c) Give the value of the organization’s total liabilities:$_________________________________

d) Give the total contract value of the work accomplished by your organization in each of the

last three (3) years:

20___ $________________ 20___ $________________ 20___ $________________

e) Give the contract value of work presently being accomplished by, or pending award to your

organization: $_________________________

f) Give the value of any judgments or liens outstanding against your organization:

$___________________________

g) Has any bonding company refused to write you a bond on any construction work? If yes,

please explain.

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h) Give the maximum value of contract work for which you could obtain Bond. $______________

III. Experience

a) Indicate the type of contracting undertaken by your organization and years of experience:

General ___________ Sub___________ Type_____________ Type____________

Type____________ Type_____________

b) State construction experience of principal members of your organization:

Name

Title (e.g.

President,

Manager,

etc.)

Construction

Experience

Years

Type of Work

(e.g. Schools,

Houses,

Hospitals, Apts.)

In What Capacity (Foreman,

Supt. Etc.)

c)

Give any special qualifications of firm members (Registered Engineer, Surveyor, etc.)

d) List some principal projects completed by your organization:

Name of Work

General or

Sub (If sub,

what work)

Your Contract

Amount

Designing

Architect or

Engineer Owners’ Name and Address

e)

If General Contractor, list sub-contractors in various fields who have worked under you:

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f) If Sub-Contractor, list some General Contractors for whom you have worked:

g) What is the money value of the largest project accomplished by your Organization?

$______________________________

Maximum value in last three (3) years: $______________________________

Maximum value you prefer to undertake: $______________________________

Price range of work your organization is deemed best adapted to undertake:

$______________________________

h) Is your organization licensed in the State of Maryland for the current year?____________

Give date and license number:

Date: ______________________ License No. ____________________________

▪Please include a copy of your current Maryland Contractor’s License with this submission.

i) Provide at least three (3) Client References: Company Name, Contact, Phone, Address

Company Name

Contact

Person

Phone

Number Email Address Address

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The above statements are certified to be true and accurate.

Dated at _______________________________this_________day of _______________________________20________.

By:

(Title of Person Signing)

(Name of Organization)

State of _________________________________

County of_______________________________, S.S.

____________________________________________________________________ being duly sworn states that he is

(Office) (Name of Organization)

And that the answers to the foregoing questions and all statements therein contained are true and correct.

Sworn to before me, this _____________ day of __________________________________20________.

________________________________________________

My Commission expires___________________________ Notary Public

DO NOT FILL IN THESE SPACES

Year Filed:

Application No.:

Reviewed by:

Date: